Asbestos Health Surveillance Form

WorkSafe Health Surveillance Notification

Asbestos

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Occupational Safety and Health Act 1984; Regulation 5.24
Confidential
Please complete all sections neatly. A copy of spirometry must be attached 44444444
Return to : Occupational Physician, WorkSafe, Locked Bag 14, Cloisters Square PERTH WA 6850
Tel: 6251 2200 Fax: 6251 2827 Email:

PART A

A 1. PERSONAL DETAILS (to be completed by employee)

Family name: / Date of birth: / M F
Given names: / Country of birth:
Address:
Current job: / Tel: / Mobile:
Date employed:
A 2. EMPLOYER DETAILS (to be completed by employee)
Employer name:
Address:
Contact name: / Tel: / Mobile:
A 3. CURRENT WORK EXPOSURE / INCIDENT (to be completed by employee)
Date/s: // - // / Time:
How were you exposed to asbestos?
(activity generating asbestos dust, proximity to source, frequency, duration of exposure, control measures, etc.)
Description of Asbestos Exposure: / o Single exposure (mins, hrs, days)
o Repeated exposure (mins, hrs, days, months, years)
Type of asbestos (if known) :
o Amosite (brown) o Chrysotile (white) o Crocidolite (blue) o unknown
o Asbestos cement products (bonded)
o Asbestos cement sheets o Telecommunication pits o Electrical boards o brake pads
o other ……………………
Condition of material containing asbestos o good o fair o poor
o Friable
o Insulation o Lagging o other
Personal Protective Equipment (PPE)
Disposable Overalls Yes No
Respirator Yes No
Laceless boots Yes No / SAFETY PRECAUTIONS e.g. wet work, ……..
Comments:
Air Monitoring (attach if results available)
A 4. WORK and ASBESTOS EXPOSURE HISTORY (to be completed by employee)
Detail past work history starting from your first to current job – Include all jobs.
If “Yes” to asbestos exposure, please describe.
Example: drill/cut asbestos cement material with power tools; put up asbestos cement fencing; demolish asbestos buildings; renovate asbestos buildings; removal of telecommunication asbestos cement pits, service brake linings; crawl through ceiling spaces with asbestos insulation; work around boilers/plants insulated with asbestos, removal/transport/disposal of asbestos; mining – asbestos contamination, etc.
Years
(yyyy to yyyy) / Employer Name & Address
(e.g. ABC asbestos removalist, local council, ABC building construction, telecommunications contractor) / Asbestos exposure
(Yes/No) / Job Title and Work Tasks
· If Yes to asbestos exposure – detail where, how, and what.
· What personal protective equipment worn, if any? Any safety controls in place? Any health monitoring?
/
A 5. NON-WORK ASBESTOS EXPOSURE HISTORY (to be completed by employee)
Please give details from your first exposure onwards
Example: Visited Wittenoom; put up asbestos cement fencing; demolished asbestos shed/buildings/fencing; home renovations; change brake linings; drill, cut asbestos cement material or sheets with power tools; lived in asbestos cement home
Years
(yyyy to yyyy) / Job Title and Work Tasks
· If Yes to asbestos exposure – detail where, how, and what.
· Any personal protective equipment worn? Any safety controls in place?
/
A 6. MEDICAL HISTORY (to be completed by employee)
1. Approximate date of last chest X-ray (if any) / Normal Abnormal (please detail)______
2. Smoking History: / Current smoker: / Ex-smoker: / Non-smoker:
Age started: / Age stopped: / Amount smoked per day (number of cigarettes/cigars or
grams of tobacco smoked)
3. Respiratory symptoms e.g cough, shortness of breath, wheeze. phlegm (describe):
Have you had: / Asthma / Pneumonia / Bronchitis / Pleurisy / Other lung/chest disease or injury
3. Provide details (diagnosis, when, treatment): / Comment by Examining Doctor
4. List any medications you currently take:
5. If you have any other health problems, please provide details
PART B - MEDICAL EXAMINATION (to be completed by examining doctor)
Height: cm / Weight: kg / BMI =
Cardiovascular: / Pulse /min / BP mm/Hg
Respiratory: / Rate /min
Breath sounds:
Other relevant findings:
Summary assessment:
Chest X-ray (CXR) Not Required: Required
Note: A CXR is not routinely recommended for a single minor event or potential exposure - but may be ordered where clinically indicated. / CXR Results (if recommended):
Spirometry: / Date of test: // / Attached spirometry printouts and graphs: 444

NHANES III preferred for spirometric predicted values)

1. Enter 3 valid test values and Best test values.

2. Attach printouts with 3 valid tests which meet ATS “acceptable blow” criteria and corresponding flow-volume graphs.

3. If used bronchodilator, please clearly marked pre- and post-bronchodilator on print-outs.
Test 1 / Test 2 / Test 3 / Best / % predicted / Comment:
FEV1 / Normal Abnormal
FVC / Obstructive Restrictive
FEV1 / FVC / Mixed Obstructive / Restrictive
Comments (examining doctor)
PART C - RESULTS OF HEALTH SURVEILLANCE (to be completed by examining doctor)
To: / Name:
Home address:
Your health surveillance assessment on // was satisfactory. / No further action required
Recommendations: / Comment
Advised to stop smoking:
Review PPE
Review Asbestos safe work practice
Repeat lung function:
Referral to respiratory physician:
Referral to own GP:
Discussed with WorkSafe OHP
Repeat health surveillance on: //
(For significant / repeated exposure e.g. asbestos removal)
Appointed Medical Practitioner (responsible for supervising health surveillance)
Name: / Signature: / Date: //
Medical Practice address:
File original document with health surveillance medical file
Copy to employee on: //
Copy to employer on: //

For information or assistance, contact:
Occupational Physician or Occupational Health Nurse, WorkSafe : 6251 2200

ASBESTOS - WorkSafe WA - Health Surveillance - Notification Form Revised April 2015 Page 1 of 4